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Cryosurgery and Electrosurgery. Adam O. Goldstein, MD Associate Professor UNC Dept Family Medicine Chapel Hill, NC aog@med.unc.edu. Objectives. Know indications and techniques for using cryotherapy to treat common dermatologic conditions

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cryosurgery and electrosurgery

Cryosurgery and Electrosurgery

Adam O. Goldstein, MD

Associate Professor

UNC Dept Family Medicine

Chapel Hill, NC

aog@med.unc.edu

objectives
Objectives
  • Know indications and techniques for using cryotherapy to treat common dermatologic conditions
  • Know indications and techniques for using electrocautery to treat common dermatologic conditions
  • Know side effects of cryotherapy and electrosurgery
cryosurgery
Cryosurgery
  • Purpose: For rapid treatment of common skin conditions
  • Benign lesions: warts, seborrheic keratoses
  • Premalignant lesions: actinic keratoses
  • Malignant tumors: Basal cell/squamous cell carcinomas
  • MUST KNOW THE DIAGNOSIS
cryosurgery1
Cryosurgery
  • Tissue destruction: -10 to -20 C.
  • Malignant cell kill: -40 to -50 C.
  • Chemical refrigerants -70 to -94 C.
  • Cold cryoprobes -90 C.
  • Liquid Nitrogen -196 C.
chemical refrigerants
Chemical Refrigerants
  • Verruca-Freeze
  • Low start-up costs
  • Useful for satellite offices
  • Not approved treatment for malignant lesions
verruca freeze
Verruca Freeze
  • Speculum size (2-12 mm) that encompasses lesion
  • 1 “freeze” cycle =
    • Fill speculum with spray 1/8- 1/4 inch (3-6 seconds)
    • Allow fluid to evaporate (20-25 sec.)
  • 130 “freezes” per cannister
  • $200 start-up costs
  • Long shelf life- 4-5 years
cryoprobes
Cryoprobes
  • Nitrous oxide cryoguns
  • Tanks with cart, hand gun, pressure gauge and regulator
  • Useful if liquid nitrogen not available
nitrous oxide
Nitrous Oxide
  • Put water soluble gel to lesion
  • Select probe size
  • Apply activated cryogun probe tip to skin
liquid nitrogen
Liquid Nitrogen

Advantages for clinician

  • Cheap after set-up costs
  • Easy to learn
  • Multiple lesions at one time
  • Do not need assistant to perform
liquid nitrogen1
Liquid Nitrogen

Advantages for patient

  • No local anesthetic needed
  • Pain tolerable
  • No sutures
  • Wound care relatively easy
liquid nitrogen2
Liquid Nitrogen

Disadvantages for clinician

  • Start-up costs $1000
  • Storage facilities
  • Filling canisters
liquid nitrogen3
Liquid Nitrogen
  • Boiling point -196 C.
  • Cellular destruction d/t:
    • ice crystal formation
    • cellular dehydration
    • protein and enzymatic denaturization
  • Destruction more pronounced with:
    • rapid freeze
    • slow thaw cycle
liquid nitrogen equipment
Liquid Nitrogen: Equipment
  • Liquid nitrogen
  • Storage tank= Dewars
  • 2-30 L, filled q 3-4 weeks
  • Costs:

Tanks: Holding timeCosts

    • 2 L 48 hrs $200
    • 10 L 6-8 weeks $475
    • 20 L 8-12 weeks $535
    • 30 L 14-16 weeks $620
liquid nitrogen equipment1
Liquid Nitrogen: Equipment
  • Filling Dewars; pouring, ladles or devices
  • Devices affixed to dewar:

Ladels Valve: $310 Tube: $150

liquid nitrogen equipment2
Liquid Nitrogen: Equipment
  • Thermos bottle with hole and cotton tipped swab or
  • Cry-AC Spray/cryogun (C-tip, mini-gun)

10 oz 16 oz 12 oz $670 $670 $650 12 hr 24 hr 24 hr

cryosurgery2
Cryosurgery
  • Frozen areas turn white = “freezeball” or “iceball”
  • Depth of freeze should be 1 X radius of freeze
  • Lethal Zone
    • Tissue temp < -20 C.
    • 2-3.5 mm inward from outer margin iceball
  • Freeze 2-3 mm beyond lesion edge
cryosurgery3
Cryosurgery

Remember …..

  • Always best to underfreeze rather than overfreeze
  • Hold canister perpendicular to skin
  • Usually 2-3 freeze/thaw cycles
cryosurgery4
Cryosurgery
  • Cotton tipped swabs
  • Informed consent-oral vs written
cryosurgery freezeball time
Cryosurgery: Freezeball Time
  • Freckles/lentigos: 3-5 seconds
  • Small papules: 5-10 seconds
  • Seborrheic Keratoses: 30-40 seconds
  • Actinic keratoses: 40-60 seconds
  • SCCa/BCCa: 80-90 seconds
cryosurgery freezeball size
Cryosurgery: Freezeball Size
  • 1mm- freckles/lentigos
  • 1-2 mm- most benign skin lesions
  • 2-3 mm- most warts
  • 3-4 mm- most actinic keratoses
  • 4-6 mm- superficial SCCa, BCCa
cryosurgery5
Cryosurgery
  • Thermocouple
  • $500 for temperature monitor and thermocouple needle
cryosurgery effectiveness
Cryosurgery: Effectiveness

Low

  • Vascular lesions: e.g. angiomas
  • Achrochordans
cryosurgery effectiveness1
Cryosurgery: Effectiveness

Medium

  • Xanthelasma
  • Dermatofibroma
  • Keloid
  • Molluscum
  • Prurigo nodularis
  • Sebaceous hyperplasia
cryosurgery effectiveness2
Cryosurgery: Effectiveness

Medium-High

  • Seborrheic keratosis
  • Verruca *
  • Condyloma acuminata
  • Lentigo
  • Freckles
cryosurgery6
Cryosurgery
  • Verruca:
    • Often resistant
    • Warts on hands
    • Plantar warts
    • Flat warts
cryosurgery effectiveness3
Cryosurgery: Effectiveness

High

  • Actinic keratosis
  • Superficial Basal Cell Carcinoma
  • Superficial Squamous Cell Carcinoma
cryosurgery superficial bcca scca
Cryosurgery: Superficial BCCa/SCCa
  • Establish pathological diagnosis first
  • Success rates > 95%
cryosurgery special populations
Cryosurgery: Special Populations
  • Children
    • In general avoid b/c pain
    • Use EMLA cream if needed
  • Useful modality for those on anticoagulants, those with pacemakers and those allergic to anesthetics
cryosurgery7
Cryosurgery

DO NOT FREEZE

  • If you do not know diagnosis
  • Recurrent skin cancers
  • Melanoma or any possibility
  • Morpheaform BCCA
  • Lip neoplasms
  • Nasolabial fold cancers
  • Compromised circulation
cryosurgery8
Cryosurgery

BE CAREFUL ABOUT FREEZING

  • Lesions on/near the eye
  • Lesions on the fingers/elbows
  • Lesions over shins, ears, genitals
  • Lesions near nails
cryosurgery9
Cryosurgery

BE CAREFUL ABOUT FREEZING

  • Patients with dark skin
  • Patients with Raynaud’s disease
  • Patients on chronic steroids
  • Patients with diabetes
  • Patients with cold induced urticaria/cryoglobulinemia
cryosurgery side effects
Cryosurgery: Side Effects

Short term:

  • Pain and erythema
  • Blister formation
  • Hemorrhage
  • Infection
  • Pyogenic granuloma
cryosurgery side effects1
Cryosurgery: Side Effects

Long term

  • Nerve damage
  • Pigmentary changes
  • Hypertrophic scar formation
  • Permanent nail dystrophy
  • Recurrence of lesion
  • Multiple visits may be needed
electrosurgery
Electrosurgery
  • Purpose:
    • Destroy tissue
    • Excise tissue
    • Coagulation
  • Often done with curettage
electrosurgery1
Electrosurgery
  • Electrocautery: Hot electrode (vs cold electrodes)
  • Electrodessication: Electrode inserted into/on skin

(“dries out” skin; “epilation” = fine dessication)

  • Fulguration: Electrode held away from skin

(“fulgur” = lightening; shallow destruction and eschar)

  • Electrocoagulation: Used for hemostasis
  • Electrosection: Used to cut tissue
  • Radiosurgery: Electrosx. with radio frequencies
electrosurgery2
Electrosurgery
  • Electricator
  • Hyfrecator
  • Bantam Bovie
  • Ritter Coagulator
  • Surgitron
electrosurgery3
Electrosurgery
  • Advantages: Easy to use, rapid, useful, hemostasis while cutting, less infection
  • Disadvantages: Electric shocks and burns/fires, hypertrophic scars, “channeling” nerves, viral shedding, delayed bleeding, slower healing, histological distortion
  • Costs: $1000-2000
electrosurgery4
Electrosurgery

IndicationsProcedure

  • Cherry angiomas dessication
  • Achrocordans dessication/fulguration
  • Telangiectasias dessication
  • Small verrucae on hands fulguration
  • Pyogenic granulomas fulguration
  • Seb Keratoses fulguration
  • Small BCCa or SCCa fulguration and curettage
electrosurgery5
Electrosurgery
  • Start at low power and increase slowly
  • Use lowest power needed for tissue destruction/cutting
electrosurgery6
Electrosurgery
  • Local anesthesia: EMLA, lidocaine
  • Avoid ethyl chloride, alcohol wipes, and oxygen
  • Keep field dry (Aluminum chloride)
  • Mask and ventilation
  • Fire extinguisher
electrosurgery and curettage c d
Electrosurgery and Curettage (C&D)
  • Useful for small BCCa or SCCa
  • Local anesthetic
  • Sharp 2 mm, 3 mm curettes
  • Scrape in different directions until “firm”
electrosurgery and curettage c d1
Electrosurgery and Curettage (C&D)
  • Electrodessicate base and 2 mm skin
  • Repeat total of three times
  • Control bleeding with Monsel’s solution
  • Wound instructions and saucerization
electrosurgery vs cryosurgery
Electrosurgery vs Cryosurgery
  • Verrucae and AK’s- Cryosurgery
  • Condyloma- Electrosurgery

(Transmission of HPV through vapors)

electrosurgery vs excision
Electrosurgery vs Excision
  • Excision preferred for histology and to minimize tissue destruction
  • Electrosurgical excision acceptable at times
  • Avoid both on feet if at all possible
electrosurgery and
Electrosurgery and ....
  • Pacemakers
  • Metal pins
  • Melanoma
conclusions
Conclusions
  • Cryosurgery and elctrosurgery are safe, effective and can be done quickly
  • Know the diagnosis first
  • Perform patient education before the procedure
that that that that s

THE END

That….that…that….that’s...

That’s all folks!!!!!!!!!!!!!